Surgical Site Infection (SSI) Event

Transcription

1 Surgical Site Infection () Event Introduction: In 2010, an estimated 16 million operative procedures were performed in acute care hospitals in the United States 1. A recent prevalence study found that s were the most common healthcare-associated infection, accounting for 31% of all HAIs among hospitalized patients 2. The CDC healthcare-associated infection (HAI) prevalence survey found that there were an estimated 157,500 surgical site infections associated with inpatient surgeries in NHSN data for (16,147 s following 849,659 operative procedures) showed an overall rate of 1.9% 4. While advances have been made in infection control practices, including improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis, s remain a substantial cause of morbidity, prolonged hospitalization, and death. is associated with a mortality rate of 3%, and 75% of associated deaths are directly attributable to the 5. Surveillance of with feedback of appropriate data to surgeons has been shown to be an important component of strategies to reduce risk 6-9. A successful surveillance program includes the use of epidemiologically-sound infection definitions and effective surveillance methods, stratification of rates according to risk factors associated with development, and data feedback 7,8. A new CDC and Healthcare Infection Control Practices Advisory Committee guideline for the prevention of surgical site infection is scheduled for publication soon, and will replace the previous Guideline for Prevention of Surgical Site Infection, Settings: Surveillance of surgical patients will occur in any inpatient and/or outpatient setting where the selected NHSN operative procedure(s) are performed. Requirements: Perform surveillance for following at least one NHSN operative procedure category (Table 1) as indicated in the Patient Safety Monthly Reporting Plan (CDC ). Collect (numerator) and operative procedure category (denominator) data on all procedures included in the selected procedure categories for at least one month to meet NHSN requirements, or as otherwise specified by mandates and other reporting requirements. A procedure must meet the NHSN definition of an operative procedure in order to be included in the surveillance. All procedures included in the NHSN monthly surveillance plan are followed for superficial, deep, and organ space s. monitoring requires active, patient-based, prospective surveillance. Post-discharge and ante-discharge surveillance methods should be used to detect s following inpatient and outpatient operative procedures. These methods include, 1) direct examination of patients wounds during follow-up visits to either surgery clinics or physicians offices, 2) review of medical records or surgery clinic patient records, 3) surgeon surveys by mail or telephone, and 4) patient surveys by mail or telephone (though patients may have a difficult time assessing their infections). Any combination of these methods is acceptable for use; however, CDC January 2015 (Modified April 2015) 9-1

2 criteria for must be used. To minimize Infection Preventionists (IPs) workload of collecting denominator data, operating room data may be downloaded (see file specifications at: An will be associated with a particular NHSN operative procedure and the facility in which that procedure was performed. Refer to the NHSN application s Help system for instruction on linking an to an operative procedure. The International Classification of Diseases, 9 th Revision Clinical Modifications (ICD-9-CM) codes, which are defined by the ICD-9 Coordination and Maintenance Committee of the National Center for Health Statistics and the Centers for Medicare and Medicaid Services (CMS), are developed as a tool for classification of morbidity data. The wide use enables the grouping of surgery types for the purpose of determining rates. Table 1 lists NHSN operative procedure category groupings by ICD-9-CM codes. Because ambulatory surgery centers and hospital outpatient surgery departments may not use ICD-9-CM procedure codes, Table 1 provides Current Procedural Terminology (CPT) code mapping for certain NHSN operative procedure categories to assist users in determining the correct NHSN code to report for outpatient surgery cases. However, when available, ICD-9-CM codes take precedence over CPT codes when determining the appropriate NHSN operative procedure category for inpatient surgery cases. Table 1 also includes a general description of the types of operations contained in the NHSN operative procedure categories. CDC continues to work on updated ICD-10-CM/PCS and CPT mappings to all NHSN operative procedure categories for surveillance. These mappings are anticipated to be available by March Note: ICD-10-CM/PCS codes will replace ICD-9-CM codes on October 1, 2015, however NHSN will not have the ability to receive these codes until the January 2016 release. The NHSN guidance for entry of surgical denominator data for the last quarter of 2015 data is to enter the NHSN Procedure Code (e.g. COLO or HYST); but do not enter any ICD-10- CM/PCS codes associated with the procedure. Note: The infection window, Present on Admission, Hospital Associated Infection and Repeat Infection Timeframe definitions should not be applied to the protocol. Definition of an NHSN Operative Procedure An NHSN Operative Procedure is a Procedure: that is included in Table 1 And takes place during an operation where at least one incision (including laparoscopic approach) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure And January 2015 (Modified April 2015) 9-2

3 takes place in an operating room (OR), defined as a patient care area that met the Facilities Guidelines Institute s (FGI) or American Institute of Architects (AIA) criteria for an operating room when it was constructed or renovated 10. This may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab. Exclusions: Otherwise eligible procedures that are assigned an ASA score of 6 are not eligible for NHSN surveillance Note: Incisional closure method is NOT a part of the NHSN operative procedure definition; all otherwise eligible procedures are included, regardless of closure type. Therefore both primarily closed procedures and those that are not closed primarily should be entered into the denominator data for procedures in the facility s monthly reporting plan. Any s attributable to either primarily closed or non-primarily closed procedures should be reported. Table 1. NHSN Operative Procedure Category Mappings to ICD-9-CM Codes and CPT Codes Notes: NHSN will provide updates as needed concerning the transition from ICD-9-CM to ICD-10-CM/PCS procedure coding. When available, ICD-9-CM codes take precedence over CPT codes when determining the appropriate NHSN operative procedure category for inpatient surgery cases. Legacy Code AAA AMP APPY AVSD Operative Procedure Abdominal aortic aneurysm repair Limb amputation Appendix surgery Shunt for dialysis Description Resection of abdominal aorta with anastomosis or replacement Total or partial amputation or disarticulation of the upper or lower limbs, including digits Operation of appendix Note: incidental APPY codes are not part of this procedure group and do not need to be reported. Arteriovenostomy for renal dialysis ICD-9-CM Codes / CPT Codes 38.34, 38.44, , , 47.09, 47.2, 47.91, 47.92, , January 2015 (Modified April 2015) 9-3

4 BILI Bile duct, liver or pancreatic surgery Excision of bile ducts or operative procedures on the biliary tract, liver or pancreas (does not include operations only on gallbladder) BRST Breast surgery Excision of lesion or tissue of breast including radical, modified, or quadrant resection, lumpectomy, incisional biopsy, or mammoplasty CARD CEA CBGB CBGC Cardiac surgery Carotid endarterectomy Coronary artery bypass graft with both chest and donor site incisions Coronary artery bypass graft with chest incision only Procedures on the heart; includes valves or septum; does not include coronary artery bypass graft, surgery on vessels, heart transplantation, or pacemaker implantation Endarterectomy on vessels of head and neck (includes carotid artery and jugular vein) Chest procedure to perform direct revascularization of the heart; includes obtaining suitable vein from donor site for grafting Chest procedure to perform direct vascularization of the heart using, for example the internal mammary (thoracic) artery 50.0, 50.12, 50.14, , 50.25, 50.26, 50.29, 50.3, 50.4, 50.61, 50.69, , 51.39, , 51.49, 51.51, 51.59, , 51.69, 51.71, 51.72, 51.79, , 51.89, , 51.99, 52.09, 52.12, 52.22, 52.3, 52.4, , , 52.7, 52.92, 52.95, 52.96, , , , , 85.50, , 85.6, , 85.79, , 19112, 19120, 19125, 19126, 19300, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, , 35.06, 35.08, , , , 35.39, 35.42, 35.50, 35.51, 35.53, 35.54, , , , , , , , , 37.41, 37.49, , , 36.2 January 2015 (Modified April 2015) 9-4

5 CHOL Gallbladder surgery Cholecystectomy and cholecystotomy COLO Colon surgery Incision, resection, or anastomosis of the large intestine; includes large-to-small and small-to-large bowel anastomosis For rectal procedures see the REC codes. CRAN Craniotomy Excision repair, or exploration of the brain or meninges; does not include taps or punctures CSEC Cesarean section Obstetrical delivery by Cesarean section FUSN Spinal fusion Immobilization of spinal column FX Open reduction of fracture Open reduction of fracture or dislocation of long bones with or without internal or external fixation; does not include placement of joint prosthesis 51.03, 51.04, 51.13, , 47562, 47563, 47564, 47600, 47605, 47610, 47612, , 17.39, 45.03, 45.26, 45.41, 45.49, 45.52, , 45.79, , , 46.03, 46.04, 46.10, 46.11, 46.13, 46.14, 46.43, 46.52, 46.75, 46.76, , 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, , 01.14, , 01.28, 01.29, 01.31, 01.32, 01.39, 01.41, 01.42, , 01.59, , , , 07.59, , 07.68, 07.69, 07.71, 07.72, 07.79, 38.01, 38.11, 38.31, 38.41, 38.51, 38.61, 38.81, , 74.1, 74.2, 74.4, 74.91, , 79.22, 79.25, 79.26, 79.31, 79.32, 79.35, 79.36, 79.51, 79.52, 79.55, , 23616, 23630, 23670, 23680, 24515, 24516, 24538, 24545, 24546, 24575, 24579, 24586, 24587, 24635, 24665, 24666, 24685, 25337, 25515, 25525, 25526, 25545, 25574, 25575, 25607, 25608, 25609, 25652, 27236, 27244, 27245, 27248, 27254, 27269, 27283, 27506, 27507, 27511, 27513, 27514, 27535, 27536, 27540, 27758, 27759, 27766, 27769, 27784, 27792, 27814, 27822, 27826, 27827, January 2015 (Modified April 2015) 9-5

6 GAST Gastric surgery Incision or excision of stomach; includes subtotal or total gastrectomy; does not include vagotomy and fundoplication HER Herniorrhaphy Repair of inguinal, femoral, umbilical, or anterior abdominal wall hernia; does not include repair of diaphragmatic or hiatal hernia or hernias at other body sites 43.0, 43.42, 43.49, 43.5, 43.6, 43.7, 43.81, 43.82, 43.89, 43.91, 43.99, 44.15, 44.21, 44.29, 44.31, , 44.49, 44.5, , , , , , , 53.21, 53.29, 53.31, 53.39, , 53.49, 53.51, 53.59, , , 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49650, 49651, 49652, 49653, 49654, 49655, 49656, 49657, 49659, HPRO Hip prosthesis Arthroplasty of hip , , , 27130, 27132, 27134, 27137, 27138, 27236, HTP Heart transplant Transplantation of heart HYST KPRO Abdominal hysterectomy Knee prosthesis Abdominal hysterectomy; includes that by laparoscope 68.31, 68.39, 68.41, 68.49, 68.61, , 58152, 58180, 58200, 58210, 58541, 58542, 58543, 58544, 58548, 58570, 58571, 58572, 58573, 58951, 58953, 58954, Arthroplasty of knee , 81.54, , 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, KTP Kidney Transplantation of kidney 55.61, transplant LAM Laminectomy Exploration or decompression of spinal cord through excision or incision into vertebral structures 03.01, 03.02, 03.09, 80.50, 80.51, 80.53, 80.54, 80.59, , January 2015 (Modified April 2015) 9-6

7 LTP Liver Transplantation of liver 50.51, transplant NECK Neck surgery Major excision or incision of the larynx and radical neck dissection; does not include thyroid and parathyroid operations NEPH Kidney surgery Resection or manipulation of the kidney with or without removal of related structures OVRY PACE PRST PVBY Ovarian surgery Pacemaker surgery Prostate surgery Peripheral vascular bypass surgery Operations on ovary and related structures Insertion, manipulation or replacement of pacemaker Suprapubic, retropubic, radical, or perineal excision of the prostate; does not include transurethral resection of the prostate Bypass operations on peripheral arteries 30.1, 30.21, 30.22, 30.29, 30.3, 30.4, 31.45, , 55.02, 55.11, 55.12, 55.24, 55.31, 55.32, 55.34, 55.35, 55.39, 55.4, 55.51, 55.52, 55.54, , 65.09, 65.12, 65.13, , 65.29, 65.31, 65.39, 65.41, 65.49, , , , 65.79, 65.81, 65.89, , , 17.51, 17.52, , , , 37.89, , 60.3, 60.4, 60.5, 60.61, REC Rectal surgery Operations on rectum 48.25, 48.35, 48.40, 48.42, 48.43, , 48.59, , 48.69, RFUSN SB Refusion of spine Small bowel surgery Refusion of spine Incision or resection of the small intestine; does not include smallto-large bowel anastomosis SPLE Spleen surgery Resection or manipulation of spleen 45.01, 45.02, 45.15, , 45.51, , 45.91, 46.01, 46.02, , 46.31, 46.39, 46.41, 46.51, , , 41.33, , 41.5, 41.93, 41.95, January 2015 (Modified April 2015) 9-7

8 THOR THYR VHYS Thoracic surgery Thyroid and/or parathyroid surgery Vaginal hysterectomy Noncardiac, nonvascular thoracic surgery; includes pneumonectomy and hiatal hernia repair or diaphragmatic hernia repair (except through abdominal approach) Resection or manipulation of thyroid and/or parathyroid Vaginal hysterectomy; includes that by laparoscope 32.09, 32.1, , 32.25, 32.26, 32.29, 32.30, 32.39, 32.41, 32.49, 32.50, 32.59, 32.6, 32.9, 33.0, 33.1, 33.20, 33.25, 33.28, , 33.39, , 33.48, 33.49, 33.98, 33.99, , 34.06, 34.1, 34.20, 34.26, 34.3, 34.4, 34.51, 34.52, 34.59, 34.6, , 34.89, 34.93, 34.99, , 06.09, 06.12, 06.2, 06.31, 06.39, 06.4, , 06.6, 06.7, 06.81, 06.89, , 06.98, , 68.59, 68.71, VSHN XLAP Ventricular shunt Exploratory laparotomy Ventricular shunt operations, including revision and removal of shunt Procedures involving an incision through abdominal wall to gain access into the abdominal cavity; diagnostic procedure on abdominal region 02.21, 02.22, , 02.39, 02.42, 02.43, , 53.72, 53.75, 54.0, 54.11, 54.12, 54.19, 54.3, 54.4, 54.51, 54.59, 54.61, 54.63, 54.64, , 54.92, Include only if this procedure involves ventricular shunt (i.e., is not a Ladd procedure to repair malrotation of intestines). For a complete list of all ICD-9-CM codes mapped to their assignment as an NHSN operative procedure category, a surgical procedure other than an NHSN operative procedure (OTH), or a non-operative procedure (NO), see ICD-9-CM Procedure Code Mapping to NHSN Operative Procedure Categories at Denominator for Procedure Definitions: ASA physical status: Assessment by the anesthesiologist of the patient s preoperative physical condition using the American Society of Anesthesiologists (ASA) Classification of Physical Status 11,12. Patient is assigned one of the following: 1. A normally healthy patient 2. A patient with mild systemic disease 3. A patient with severe systemic disease 4. A patient with severe systemic disease that is a constant threat to life 5. A moribund patient who is not expected to survive without the operation. January 2015 (Modified April 2015) 9-8

9 Note: Do NOT report procedures with an ASA physical status of 6 (a declared brain-dead patient whose organs are being removed for donor purposes) to NHSN. Date of event (DOE): For an the date of event is the date when the first element used to meet the infection criterion occurs for the first time during the surveillance period. Synonym: infection date. Diabetes: The NHSN surveillance definition of diabetes indicates that the patient has a diagnosis of diabetes requiring management with insulin or a non-insulin anti-diabetic agent. This includes patients with insulin resistance who are on management with anti-diabetic agents. This also includes patients with a diagnosis of diabetes who are noncompliant with their diabetes medications. The discharge ICD-9-CM codes in the 250 to range are also acceptable for use to answer YES to the diabetes field question. The NHSN definition excludes patients with no diagnosis of diabetes. The definition excludes patients who receive insulin for perioperative control of hyperglycemia but have no diagnosis of diabetes. Duration of operative procedure: The interval in hours and minutes between the Procedure/Surgery Start Time, and the Procedure/Surgery Finish Time, as defined by the Association of Anesthesia Clinical Directors (AACD) 13 : Procedure/Surgery Start Time (PST): Time when the procedure is begun (e.g., incision for a surgical procedure). Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct, all postoperative radiologic studies to be done in the OR are completed, all dressings and drains are secured, and the physicians/surgeons have completed all procedure-related activities on the patient. Emergency operative procedure: A nonelective, unscheduled operative procedure. Emergency operative procedures are those that do not allow for the standard immediate preoperative preparation normally done within the facility for a scheduled operation (e.g., stable vital signs, adequate antiseptic skin preparation, colon decontamination in advance of colon surgery, etc.). General anesthesia: The administration of drugs or gases that enter the general circulation and affect the central nervous system to render the patient pain free, amnesic, unconscious, and often paralyzed with relaxed muscles. Height: The patient s most recent height documented in the medical record in feet (ft.) and inches (in), or meters (m). NHSN Inpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and the date of discharge are different calendar days. January 2015 (Modified April 2015) 9-9

10 NHSN Outpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and date of discharge are the same calendar day. Non-primary Closure is defined as closure that is other than primary and includes surgeries in which the skin level is left completely open during the original surgery and therefore cannot be classified as having primary closure. For surgeries with non-primary closure, the deep tissue layers may be closed by some means (with the skin level left open), or the deep and superficial layers may both be left completely open. An example of a surgery with non-primary closure would be a laparotomy in which the incision was closed to the level of the deep tissue layers, sometimes called fascial layers or deep fascia, but the skin level was left open. Another example would be an open abdomen case in which the abdomen is left completely open after the surgery. Wounds with non-primary closure may or may not be described as "packed with gauze or other material, and may or may not be covered with plastic, wound vacs, or other synthetic devices or materials. Primary Closure is defined as closure of the skin level during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision. This category includes surgeries where the skin is closed by some means. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery. Note: If a procedure has multiple incision/laparoscopic trocar sites and any of the incisions are closed primarily then the procedure technique is recorded as primary closed. Scope: An instrument used to visualize the interior of a body cavity or organ. In the context of an NHSN operative procedure, use of a scope involves creation of several small incisions to perform or assist in the performance of an operation rather than use of a traditional larger incision (i.e., open approach). Robotic assistance is considered equivalent to use of a scope for NHSN surveillance. See also Instructions for Completion of Denominator for Procedure Form and both Numerator Data and Denominator Data reporting instructions in this chapter. Note: If a scope site has to be extended for hand assist or removal of specimen this will still meet scope = Yes. If the procedure is converted to an open procedure it will be scope = No. Secondary BSI Attribution Period: The secondary BSI attribution period for is a 17-day period that includes the date of event, 3 days prior and 13 days after. Trauma: Blunt or penetrating injury occurring prior to the start of the procedure. Weight: The patient s most recent weight documented in the medical record in pounds (lbs.) or kilograms (kg) prior to or otherwise closest to the procedure. January 2015 (Modified April 2015) 9-10

11 Wound class: An assessment of the degree of contamination of a surgical wound at the time of the operation. Wound class should be assigned by a person involved in the surgical procedure (e.g., surgeon, circulating nurse, etc.). The wound class system used in NHSN is an adaptation of the American College of Surgeons wound classification schema. There are a group of NHSN procedures that can never be coded as clean. NHSN reached the decision regarding which NHSN operative procedures can never be classified as clean based on feedback from external experts in the field of surgery. The procedures that can never be entered as clean are: APPY, BILI, CHOL, COLO, REC, SB and VHYS. Therefore, for these procedures in the application clean is not an option on the drop down menu. For all other procedures clean is available as a choice and if the surgical team deems the procedure to be clean it can be entered as such into the NHSN application. For example CSEC, HYST, or OVRY can be a clean wound class if documented as such. Wounds are divided into four classes: 1. Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. Note: The clean wound classification level will not be available for denominator data entry for the following NHSN operative procedure categories: APPY, BILI, CHOL, COLO, REC, SB, and VHYS 2. Clean-Contaminated: Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. 3. Contaminated: Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered including necrotic tissue without evidence of purulent drainage (e.g., dry gangrene) are included in this category. 4. Dirty or Infected: Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. January 2015 (Modified April 2015) 9-11

12 Table 2. Surgical Site Infection Criteria Criterion Surgical Site Infection () Superficial incisional Must meet the following criteria: Infection occurs within 30 days after any NHSN operative procedure (where day 1 = the procedure date), including those coded as OTH * AND involves only skin and subcutaneous tissue of the incision AND patient has at least one of the following: a. purulent drainage from the superficial incision. b. organisms isolated from an aseptically-obtained culture from the superficial incision or subcutaneous tissue. c. superficial incision that is deliberately opened by a surgeon, attending physician** or other designee and is culture positive or not cultured AND patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat. A culture negative finding does not meet this criterion. d. diagnosis of a superficial incisional by the surgeon or attending physician** or other designee. * Comments ** The term attending physician for the purposes of application of the NHSN criteria may be interpreted to mean the surgeon(s), infectious disease, other physician on the case, emergency physician or physician s designee (nurse practitioner or physician s assistant). There are two specific types of superficial incisional s: 1. Superficial Incisional Primary (SIP) a superficial incisional that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB) 2. Superficial Incisional Secondary (SIS) a superficial incisional that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CBGB) January 2015 (Modified April 2015) 9-12

13 Reporting Instructions for Superficial The following do not qualify as criteria for meeting the NHSN definition of superficial : Diagnosis/treatment of cellulitis (redness/warmth/swelling), by itself, does not meet criterion d for superficial incisional. An incision that is draining or culture (+) is not considered a cellulitis. A stitch abscess alone (minimal inflammation and discharge confined to the points of suture penetration) A localized stab wound or pin site infection. While it would be considered either a skin (SKIN) or soft tissue (ST) infection, depending on its depth, it is not reportable under this module. Note: a laparoscopic trocar site for an NHSN operative procedure is not considered a stab wound. Circumcision is not an NHSN operative procedure. An infected circumcision site in newborns is classified as CIRC and is not reportable under this module. An infected burn wound is classified as BURN and is not reportable under this module. Deep incisional Must meet the following criteria: Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the list in Table 3 AND involves deep soft tissues of the incision (e.g., fascial and muscle layers) AND patient has at least one of the following: a. purulent drainage from the deep incision. b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician** or other designee and is culture positive or not cultured AND patient has at least one of the following signs or symptoms: fever (>38 C); localized pain or tenderness. A culture negative finding does not meet this criterion. c. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test. ** The term attending physician for the purposes of application of the NHSN criteria may be interpreted to mean the surgeon(s), infectious disease, other physician on the case, emergency physician or physician s designee (nurse practitioner or physician s assistant). January 2015 (Modified April 2015) 9-13

14 Comments There are two specific types of deep incisional s: 1. Deep Incisional Primary (DIP) a deep incisional that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB) 2. Deep Incisional Secondary (DIS) a deep incisional that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CBGB) Organ/Space Must meet the following criteria: Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the list in Table 3 AND infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure AND patient has at least one of the following: a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test AND meets at least one criterion for a specific organ/space infection site listed in Table 4. These criteria are in the Surveillance Definitions for Specific Types of Infections chapter. January 2015 (Modified April 2015) 9-14

15 Table 3. Surveillance Period for Deep Incisional or Organ/Space Following Selected NHSN Operative Procedure Categories. Day 1 = the date of the procedure. 30-day Surveillance Code Operative Procedure Code Operative Procedure AAA Abdominal aortic aneurysm repair LAM Laminectomy AMP Limb amputation LTP Liver transplant APPY Appendix surgery NECK Neck surgery AVSD Shunt for dialysis NEPH Kidney surgery BILI Bile duct, liver or pancreatic surgery OVRY Ovarian surgery CEA Carotid endarterectomy PRST Prostate surgery CHOL Gallbladder surgery REC Rectal surgery COLO Colon surgery SB Small bowel surgery CSEC Cesarean section SPLE Spleen surgery GAST Gastric surgery THOR Thoracic surgery HTP Heart transplant THYR Thyroid and/or parathyroid surgery HYST Abdominal hysterectomy VHYS Vaginal hysterectomy KTP Kidney transplant XLAP Exploratory Laparotomy OTH Other NHSN operative procedures not included in these categories 90-day Surveillance Code Operative Procedure BRST Breast surgery CARD Cardiac surgery CBGB Coronary artery bypass graft with both chest and donor site incisions CBGC Coronary artery bypass graft with chest incision only CRAN Craniotomy FUSN Spinal fusion FX Open reduction of fracture HER Herniorrhaphy HPRO Hip prosthesis KPRO Knee prosthesis PACE Pacemaker surgery PVBY Peripheral vascular bypass surgery RFUSN Refusion of spine VSHN Ventricular shunt Note: Superficial incisional s are only followed for a 30-day period for all procedure types. January 2015 (Modified April 2015) 9-15

16 Table 4. Specific Sites of an Organ/Space. Code Site Code Site BONE Osteomyelitis LUNG Other infections of the respiratory tract BRST Breast abscess or mastitis MED Mediastinitis CARD Myocarditis or pericarditis MEN Meningitis or ventriculitis DISC Disc space ORAL Oral cavity (mouth, tongue, or gums) EAR Ear, mastoid OREP Other infections of the male or female reproductive tract EMET Endometritis PJI Periprosthetic Joint Infection ENDO Endocarditis SA Spinal abscess without meningitis EYE Eye, other than conjunctivitis SINU Sinusitis GIT GI tract UR Upper respiratory tract HEP Hepatitis USI Urinary System Infection IAB Intraabdominal, not specified VASC Arterial or venous infection IC Intracranial, brain abscess or dura VCUF Vaginal cuff JNT Joint or bursa (Criteria for these sites can be found in the NHSN Help system [must be logged in to NHSN] or the Surveillance Definitions for Specific Types of Infections chapter). Numerator Data: All patients having any of the procedures included in the selected NHSN operative procedure category(s) are monitored for signs of. The Surgical Site Infection () form is completed for each such patient found to have an. If no events are identified during the surveillance month, check the Report No Events field in the Missing PA Events tab of the Incomplete/Missing List. The Instructions for Completion of the Surgical Site Infection form include brief instructions for collection and entry of each data element on the form. The form includes patient demographic information and information about the operative procedure, including the date and type of procedure. Information about the includes the date of, specific criteria met for identifying the, when/how the was detected, whether the patient developed a secondary bloodstream infection, whether the patient died, and the organisms isolated from cultures and the organisms antimicrobial susceptibilities. January 2015 (Modified April 2015) 9-16

17 Event Reporting Instructions: 1. Attributing to an NHSN procedure when there is evidence of infection at the time of the primary surgery: POA definition does not apply to the protocol. If there was evidence of infection at the time of the procedure and then later in the surveillance period the patient develops an infection that meets the NHSN criteria it is attributed to the procedure (see PATOS below). A high wound class is not exclusion for a patient later meeting criteria for an. 2. Infection present at time of surgery (PATOS): PATOS denotes that there is evidence of an infection or abscess at the start of or during the index surgical procedure (in other words, it is present preoperatively). PATOS is a YES/NO field on the Event form. PATOS does not apply if there is a period of wellness between the time of a preoperative condition and surgery. The evidence of infection or abscess must be noted/documented preoperatively or found intraoperatively in a pre-operative or intraoperative note. Only select PATOS = YES if it applies to the depth of that is being attributed to the procedures (e.g., if a patient had evidence of an intraabdominal infection at the time of surgery and then later return with an organ space the PATOS field would be selected as a YES. If the patient returned with a superficial or deep incisional the PATOS field would be selected as a NO). The patient does not have to meet the NHSN definition of an at the time of the primary procedure but there must be notation that there is evidence of an infection or abscess present at the time of surgery. a) Example: Patient admitted with an acute abdomen. Sent to OR for an XLAP where there is a finding of an abscess due to ruptured appendix and an APPY is performed. Patient returns two weeks later and meets criteria for an organ space IAB. The PATOS field would be selected as YES on the event. b) Example: Patient is admitted with a ruptured diverticulum. In the OR note the surgeon documents that there are multiple abscesses in the intraabdominal cavity. Patient returns three weeks later and meets criteria for a superficial. The PATOS field would be selected as NO since there was no documentation of evidence of infection or abscess of the superficial area at the time of the procedure. c) Example: During an unplanned cesarean section (CSEC) the surgeon nicks the bowel and there is contamination of the intraabdominal cavity. One week later the patient returns and meets criteria for an organ space OREP (other reproductive). The PATOS field would be selected as NO since there was no documentation of evidence of infection or abscess at the time of the CSEC. The colon nick was a complication but there was no infection present at the time of surgery. January 2015 (Modified April 2015) 9-17

18 3. Multiple tissue levels are involved in the infection: The type of (superficial incisional, deep incisional, or organ/space) reported should reflect the deepest tissue layer involved in the infection during the surveillance period: a) Report infection that involves the organ/space as an organ/space, whether or not it also involves the superficial or deep incision sites. b) Report infection that involves the superficial and deep incisional sites as a deep incisional. c) If an started as a superficial on day 10 of the surveillance period and then a week later, (day 17 of the surveillance period) meets criteria for a deep incisional the date of event would be the date the of deep incisional. 4. Reporting of after a non-primary closure: If a patient develops an after a nonprimary closure it should be reported as attributable to that procedure if it meets criteria for an within the surveillance period. 5. Attributing to a NHSN procedure when several are performed on different dates: If a patient has several NHSN operative procedures performed on different dates prior to an infection, report the operative procedure code of the operation that was performed most closely in time prior to the infection date, unless there is evidence that the infection was associated with a different operation. Note: for multiple NHSN operative procedures performed within a 24 hour period, see Denominator Reporting Instruction #9. 6. Attributing to NHSN procedures that involve multiple primary incision sites: If multiple primary incision sites of the same NHSN operative procedure become infected, only report as a single, and assign the type of (superficial incisional, deep incisional, or organ/space) that represents the deepest tissue level involved at any of the infected sites. For example: a) If one laparoscopic incision meets criteria for a superficial incisional and another meets criteria for a deep incisional, only report one deep incisional. b) If one or more laparoscopic incision sites meet criteria for superficial incisional but the patient also has an organ/space related to the laparoscopic procedure, only report one organ/space. c) If an operative procedure is limited to a single breast and involves multiple incisions in that breast that become infected, only report a single. d) In a colostomy formation or reversal (take down) procedure, the stoma and other abdominal incision sites are considered primary incisions. If both the stoma and another abdominal incision site develop superficial incisional, report only as one (SIP). 7. Attributing to NHSN procedures that have secondary incision sites: Certain procedures can involve secondary incisions (i.e., BRST, CBGB, CEA, FUSN, PVBY, REC, RFUSN, and VSHN). The surveillance period for all secondary sites is 30 days, regardless of the required deep incisional or organ/space surveillance period for the January 2015 (Modified April 2015) 9-18

19 primary incision site(s) (Table 3). Procedures meeting this designation are reported as only one operative procedure. For example: a) A saphenous vein harvest incision site in a CBGB procedure is considered the secondary incision. One CBGB procedure is reported, the saphenous vein harvest site is monitored for 30 days after surgery for, and the chest incision is monitored for 90 days. If the patient has a superficial infection of the leg site and a deep incisional of the chest site two s are reported. b) A tissue harvest site (e.g., Transverse Rectus Abdominis Myocutaneous [TRAM] flap) in a BRST procedure is considered the secondary incision site. One BRST procedure is reported, and if the secondary incision gets infected, report as either SIS or DIS as appropriate. 8. detected at another facility: It is required that if an is detected at a facility other than the one in which the operation was performed, notify the IP of the index facility with enough detail so the infection can be reported to NHSN. When reporting the, the index facility should indicate that Detected = RO (Readmission to facility other than where procedure was performed). 9. Attribution after Multiple types of NHSN procedures are performed during a single trip to the OR: If more than one NHSN operative procedure category was performed through a single incision/laparoscopic sites during a single trip to the operating room, attribute the to the procedure that is thought to be associated with the infection. If it is not clear, as is often the case when the infection is an incisional, use the NHSN Principal Operative Procedure Category Selection Lists (Table 5) to select the operative procedure to which the should be attributed. For example, if a patient develops after a single trip to the OR in which both a COLO and SB were performed, and the source of the is not apparent, assign the to the COLO procedure. 10. following invasive manipulation/accession of the operative site: If during the postoperative period the surgical site has an invasive manipulation/accession for diagnostic or therapeutic purposes (e.g., needle aspiration), and following this manipulation/accession an develops, the infection is not attributed to the operation. This reporting instruction does NOT apply to closed manipulation (e.g., closed reduction of a dislocated hip after an orthopedic procedure). Invasive manipulation does not include wound packing, or changing of wound packing materials as part of postoperative care. 11. Reporting instructions for specific post-operative infection scenarios: An that otherwise meets the NHSN definitions should be reported to NHSN without regard to postoperative accidents, falls, inappropriate showering or bathing practices, or other occurrences that may or may not be attributable to patients intentional or unintentional postoperative actions. Also, should also be reported regardless of the presence of certain skin conditions (e.g., dermatitis, blister, impetigo) that occur near an incision, and regardless of the possible occurrence of a seeding event from an unrelated procedure (e.g., dental work). This instruction concerning various postoperative circumstances is January 2015 (Modified April 2015) 9-19

20 necessary to reduce subjectivity and data collection burden associated with the previously exempted scenarios. Table 5. NHSN Principal Operative Procedure Category Selection Lists (The following lists are derived from the operative procedures listed in Table 1. The categories with the highest risk of are listed before those with lower risks). Priority Code Abdominal Operations 1 LTP Liver transplant 2 COLO Colon surgery 3 BILI Bile duct, liver or pancreatic surgery 4 SB Small bowel surgery 5 REC Rectal surgery 6 KTP Kidney transplant 7 GAST Gastric surgery 8 AAA Abdominal aortic aneurysm repair 9 HYST Abdominal hysterectomy 10 CSEC Cesarean section 11 XLAP Laparotomy 12 APPY Appendix surgery 13 HER Herniorrhaphy 14 NEPH Kidney surgery 15 VHYS Vaginal Hysterectomy 16 SPLE Spleen surgery 17 CHOL Gall bladder surgery 18 OVRY Ovarian surgery Priority Code Thoracic Operations 1 HTP Heart transplant 2 CBGB Coronary artery bypass graft with donor incision(s) 3 CBGC Coronary artery bypass graft, chest incision only 4 CARD Cardiac surgery 5 THOR Thoracic surgery Priority Code Neurosurgical (Brain/Spine) Operations 1 VSHN Ventricular shunt 2 RFUSN Refusion of spine 3 CRAN Craniotomy 4 FUSN Spinal fusion 5 LAM Laminectomy Priority Code Neck Operations 1 NECK Neck surgery 2 THYR Thyroid and or parathyroid surgery January 2015 (Modified April 2015) 9-20